Effective Date:
Your Name:
Your Address:	Street   State	City Zip
Email Address:
Phone Number:
Liability Limits and Coverages:
Bodily Injury	12,500 - 25,000 25,000 - 50,000 50,000 - 100,000 100,000 - 300,000 250,000 - 500,000 No Coverage (comp only)
Property Damage	7,500 10,000 15,000 20,000 25,000 50,000 100,000
Medical Payments	500 1,000 2,000 5,000 10,000
Uninsured Motorists	Matching Bi Limits No Coverage
Uninsured Motorists Property Damage	7,500 No Coverage
Additional Comments
Your Vehicles:
	NOTE: If you have more than four vehicles, please call our office for a quote. Vehicle One Year Make/Model VIN Passive Restraint Driver Side Airbag Driver & Passenger Airbags Front & Side Airbags None Vehicle Use Business Work/School Pleasure Farm Miles to Work/School up to 14 miles over 15 miles N/A Comprehensive No Coverage 0 ded 50 ded 100 ded 200 ded 250 ded 500 ded 1,000 ded Collision No Coverage 0 ded 50 ded 100 ded 200 ded 250 ded 500 ded 1,000 ded Optional Coverages: Check all that apply Towing and Labor Rental Reimbursement Loan Lease Gap	NOTE: If you have more than four vehicles, please call our office for a quote. Vehicle Two Year Make/Model VIN Passive Restraint Driver Side Airbag Driver & Passenger Airbags Front & Side Airbags None Vehicle Use Business Work/School Pleasure Farm Miles to Work/School up to 14 miles over 15 miles N/A Comprehensive No Coverage 0 ded 50 ded 100 ded 200 ded 250 ded 500 ded 1,000 ded Collision No Coverage 0 ded 50 ded 100 ded 200 ded 250 ded 500 ded 1,000 ded Optional Coverages: Check all that apply Towing and Labor Rental Reimbursement Loan Lease Gap
Drivers:
	Driver 1: Name: DOB: Sex: Marital Status: Driver 1 Occupation: Drivers License Number: Has Driver 1 had any accidents or violations in the past 3 years? If yes, please explain below: Good Student Discount: GPA=3.0+ School is over 100 miles away. Please use the box below to enter any additional comments:	Driver 2: Name: DOB: Sex: Marital Status: Driver 2 Occupation: Drivers License Number: Has Driver 2 had any accidents or violations in the past 3 years? If yes, please explain below: Good Student Discount: GPA=3.0+ School is over 100 miles away. Please use the box below to enter any additional comments: